Home
Types of Equipment
Image Gallery
Online Application
Contact Us
Driver's Application for Qualification

Position's Applied for: Local/Daily   Regional   O.T.R.
First Name     Middle Name     Last Name     Social Security #

List your addresses of residency for the past 3 years:
Current Address

Street

City

State

Zip
() -
Phone
How long have you occupied the residence? () -
Cell Phone
Previous Addresses

Street

City

State

Zip
How Long?

Street

City

State

Zip
How Long?

Street

City

State

Zip
How Long?

Date of Birth:   / /
   Month  /   Day   /     Year
Do you have the legal right to work in the United States? Yes   No
If no, please explain:

Have you worked for this company before? Yes No Dates: From to
If yes above, reason for leaving:


How did you hear about us? Newspaper:      Referred by:


Is there any reason you might be unable to perform the essential functions of the job for which you have applied?   Yes No
Essential Functions: There may be duties in addition to the driving task for which a driver is responsible and needs to be fit. Some of these responsibilities are: coupling and uncoupling trailer(s), lifting, installing, and removing heavy chains, binders, and occasionally tarps. These tasks demand the ability to bend and stoop, the ability to maintain a crouching position to inspect the underside of the vehicle, frequent entering and exiting of the cab, and the ability to climb ladders on the tractor and/or trailer(s).

If yes, explain:


EMPLOYMENT HISTORY

All driver applicants to drive in interstate commerce must provide the following information on all employment (including non-driving jobs) during the preceding 3 years. List complete mailing address, street number, city, state, zip, phone #, and dates employed.
Applicants to drive a commercial motor vehicle in intrastate or interstate commerce shall also provide an additional 7 years information on those employers for whom the applicant operated such vehicle.

Note: List all employers in reverse order starting with the most recent.

Employer 1
Name From
To
Address Position Held
City              State             Zip Contact Person
Reason for Leaving Phone Number
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug & alcohol testing requirements of 49CFR part 40? (Was your job part of a pre or random testing program?) Yes No
Were you subject to the FMCSR"s (Federal Motor Carrier Safety Regulations) while employed? Yes No

Employer 2
Name From
To
Address Position Held
City              State             Zip Contact Person
Reason for Leaving Phone Number
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug & alcohol testing requirements of 49CFR part 40? (Was your job part of a pre or random testing program?) Yes No
Were you subject to the FMCSR"s (Federal Motor Carrier Safety Regulations) while employed? Yes No

Employer 3
Name From
To
Address Position Held
City              State &nbs;           Zip Contact Person
Reason for Leaving Phone Number
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug & alcohol testing requirements of 49CFR part 40? (Was your job part of a pre or random testing program?) Yes No
Were you subject to the FMCSR"s (Federal Motor Carrier Safety Regulations) while employed? Yes No

Employer 4
Name From
To
Address Position Held
City              State &nbs;           Zip Contact Person
Reason for Leaving Phone Number
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug & alcohol testing requirements of 49CFR part 40? (Was your job part of a pre or random testing program?) Yes No
Were you subject to the FMCSR"s (Federal Motor Carrier Safety Regulations) while employed? Yes No

Employer 5
Name From
To
Address Position Held
City              State &nbs;           Zip Contact Person
Reason for Leaving Phone Number
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug & alcohol testing requirements of 49CFR part 40? (Was your job part of a pre or random testing program?) Yes No
Were you subject to the FMCSR"s (Federal Motor Carrier Safety Regulations) while employed? Yes No

Employer 6
Name From
To
Address Position Held
City              State &nbs;           Zip Contact Person
Reason for Leaving Phone Number
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug & alcohol testing requirements of 49CFR part 40? (Was your job part of a pre or random testing program?) Yes No
Were you subject to the FMCSR"s (Federal Motor Carrier Safety Regulations) while employed? Yes No

Employer 7
Name From
To
Address Position Held
City              State &nbs;           Zip Contact Person
Reason for Leaving Phone Number
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug & alcohol testing requirements of 49CFR part 40? (Was your job part of a pre or random testing program?) Yes No
Were you subject to the FMCSR"s (Federal Motor Carrier Safety Regulations) while employed? Yes No

Employer 8
Name From
To
Address Position Held
City              State &nbs;           Zip Contact Person
Reason for Leaving Phone Number
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug & alcohol testing requirements of 49CFR part 40? (Was your job part of a pre or random testing program?) Yes No
Were you subject to the FMCSR"s (Federal Motor Carrier Safety Regulations) while employed? Yes No

Employer 9
Name From
To
Address Position Held
City              State &nbs;           Zip Contact Person
Reason for Leaving Phone Number
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug & alcohol testing requirements of 49CFR part 40? (Was your job part of a pre or random testing program?) Yes No
Were you subject to the FMCSR"s (Federal Motor Carrier Safety Regulations) while employed? Yes No

Employer 10
Name From
To
Address Position Held
City              State &nbs;           Zip Contact Person
Reason for Leaving Phone Number
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug & alcohol testing requirements of 49CFR part 40? (Was your job part of a pre or random testing program?) Yes No
Were you subject to the FMCSR"s (Federal Motor Carrier Safety Regulations) while employed? Yes No

Employer 11
Name From
To
Address Position Held
City              State &nbs;           Zip Contact Person
Reason for Leaving Phone Number
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug & alcohol testing requirements of 49CFR part 40? (Was your job part of a pre or random testing program?) Yes No
Were you subject to the FMCSR"s (Federal Motor Carrier Safety Regulations) while employed? Yes No

Includes vehicles having a GVWR of 26,001 lbs or more, vehicles designed to transport 16 or more passengers (including the driver), or any size vehicle used to transport hazardous materials in a quantity requiring placarding.

The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed to use to transport more than 8 passengers (including the driver), OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.

Accident Record for the past 3 years or more.
Have you had you any accidents for the past 3 years or more? Yes No

Dates  

Nature of Accident
(Backing, Rear End, Rollover, Turning, etc)
Location Amount Fatalities Injuries
Last Accident:
Next Previous:
Next Previous:
Next Previous:
Next Previous:


Traffic Convictions and forfeitures for the past 3 years (other than parking violations).
Have you had you any traffic convictions and forfeitures in the past 3 years (other than parking violations)? Yes No

Date Location Charge Penalty


Experience and Qualifications

List all driver licenses or permits held in the past 3 years.

DRIVER
LICENSES
State
License No
Type
Endorsements
Expiration Date

A) Have you ever been denied a license, permit, or priviledge to operate a motor vehicle? Yes No
B) Has any license, permit, or privledge ever been suspended or revoked? Yes No
C) Have you ever been convicted of a DUI or DWI? Yes No
D) Have you ever been convicted of a felony or misdemeanor? Yes No
If yes to any of the above questions, give details:


Driving Experience
Class of Equipment
Type of Equipment
(Van, Reefer, Hopper, Tanker, Flat, Etc.)
Dates
Approx Number of Miles
Straight Truck

From
To
Tractor & Semi-Trailer

From
To
Tractor - 2 Trailers

From
To
Motorcoach / Bus

-

From
To
Other

From
To

Class A License originall issued when?

Total number of years of Tractor / Trailer experience:

Select all areas that you have driven in: Local West Midwest South East Mountains 48 States
Canada Mexico


- OR- List states operated in for last 5 years:

Special cources or training that will help you as a driver:

Which safe driving awards do you hold and from whom?



Please select Highest Grade Completed (Grade School):
1 2 3 4 5 6 7 8 9 10 11 12
College:
1 2 3 4 5                    
Post-Graduate:
1 2 3 4



PREVIOUS PRE-EMPLOYMENT EMPLOYEE ALCOHOL & DRUG TEST STATEMENT
Section 40.25(j) As the employer, you must also ask the employee whether he or she has tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which the employee applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past three years. If the employee admits that he / she had a positive test or a refusal to test, you must not use the employee to perform safety-sensitive functions for you, until & unless the employee provides documents of successful completion of the return-to-duty process (see section 40.25(b)(5) and (e)).

The prospective employee is required by Sec. 40.25(j) to respond to the following questions.

1). Have you tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which you applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past three years?
Check One: Yes No

2). If you answered yes, can you provide / obtain proof that you've successfully completed the DOT return-to-duty requirements?
Check One: Yes No


FAIR CREDIT REPORTING ACT DISCLOSURE STATEMENT
In accordance with the previous Sections 604(b)(2)(A) of the Fair Credit Reporting Act, (Public Law 91-508), as amended by the Consumer Credit Reporting Act of 1996 (Title II, Subtitle D, Chapter 1, of Public Law 104-208), you are being informed that reports verifying your previous employment, driving record and previous drug and alcohol test results may be obtained on you for employment purposes. These reports are required by Sections 382.413, 391.25 and 391.25 of the Federal Motor Carrier Safety Regulations.

PRE-EMPLOYMENT SCREENING PROGRAM (PSP)
The Pre-Employment Screening Program (PSP) is a screening tool that allows motor carriers & individual drivers to purchase driving records from the Federal Motor Carrier Safety Administration’s (FMCSA) Motor Carrier Management Information System (MCMIS). Driver Information Resource records purchased through PSP contain the most recent 5 years of crash data and 3 years of roadside inspection data from the FMCSR MCMIS system.
By completing the certification below, you are certifying, that you are authorizing a commercial driver record of crash and inspection data ("DIR") for yourself, who is not present employee(s) of this company, solely for the purposes of pre-employment screening.

IMPORTANT NOTICE
REGARDING BACKGROUND REPORTS FROM THE PSP Online Service
1. In connection with your application for employment with Precast Haulers, Inc. (“Prospective Employer”), Prospective Employer, its employees, agents or contractors may obtain one or more reports regarding your driving, and safety inspection history from the Federal Motor Carrier Safety Administration (FMCSA).

When the application for employment is submitted in person, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer will provide you with a copy of the report upon which its decision was based and a written summary of your rights under the Fair Credit Reporting Act before taking any final adverse action. If any final adverse action is taken against you based upon your driving history or safety report, the Prospective Employer will notify you that the action has been taken and that the action was based in part or in whole on this report.

When the application for employment is submitted by mail, telephone, computer, or other similar means, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer must provide you within three business days of taking adverse action oral, written or electronic notification: that adverse action has been taken based in whole or in part on information obtained from FMCSA; the name, address, and the toll free telephone number of FMCSA; that the FMCSA did not make the decision to take the adverse action and is unable to provide you the specific reasons why the adverse action was taken; and that you may, upon providing proper identification, request a free copy of the report and may dispute with the FMCSA the accuracy or completeness of any information or report. If you request a copy of a driver record from the Prospective Employer who procured the report, then, within 3 business days of receiving your request, together with proper identification, the Prospective Employer must send or provide to you a copy of your report and a summary of your rights under the Fair Credit Reporting Act.

The Prospective Employer cannot obtain background reports from FMCSA unless you consent in writing.

If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below:

2. I authorize Precast Haulers, Inc. (“Prospective Employer”) to access the FMCSA Pre-Employment Screening Program (PSP) system to seek information regarding my commercial driving safety record and information regarding my safety inspection history. I understand that I am consenting to the release of safety performance information including crash data from the previous five (5) years and inspection history from the previous three (3) years. I understand and acknowledge that this release of information may assist the Prospective Employer to make a determination regarding my suitability as an employee.

3. I further understand that neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. I understand I may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. If I am challenging crash or inspection information reported by a State, FMCSA cannot change or correct this data. I understand my request will be forwarded by the DataQs system to the appropriate State for adjudication.

4. Please note: Any crash or inspection in which you were involved will display on your PSP report. Since the PSP report does not report, or assign, or imply fault, it will include all Commercial Motor Vehicle (CMV) crashes where you were a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, all inspections, with or without violations, appear on the PSP report. State citations associated with FMCSR violations that have been adjudicated by a court of law will also appear, and remain, on a PSP report.


I have read the above Notice Regarding Background Reports provided to me by Prospective Employer and I understand that if I sign this consent form, Prospective Employer may obtain a report of my crash and inspection history. I hereby authorize Prospective Employer and its employees, authorized agents, and/or affiliates to obtain the information authorized above.

INVESTIGATIVE CONSUMER REPORT DISCLOSURE
In connection with your employment or application for employment (including contract for services), an investigative consumer report and consumer reports, which may contain public record information, may be requested from DAC / USIS Commercial Services. These reports may include the following types of information: names and dates of previous employers, reason for termination of employment, work experience, accidents, academic history, professional credentials, drug/alcohol use, information relating to your character, general reputation, personal characteristics, mode of living, educational background, or any other information about you which may reflect upon your potential for employment gathered from any individual, organization, entity, agency, or other source which may have knowledge concerning any such items of information. Such reports may contain public record information concerning your driving record, workers' compensation claims, credit, bankruptcy proceedings, criminal records, etc., from federal, state, and other agencies which maintain such records; as well as information from DAC / USIS concerning previous driving record requests made by others from such state agencies.

You have the right to receive, upon your written request within reasonable period of time, (not to exceed 30 days) a complete and accurate disclosure of the nature and scope of the investigation requested. You have the right to make a request to DAC / USIS, upon proper identification, to request the nature and substance of all information in its files on you at the time of your request, including the sources of information, and the recipients of any reports on you that DAC / USIS has previously furnished within the two-year period preceding your request. DAC / USIS may be contacted by mail at P.O. Box 33181, Tulsa, Oklahoma, 74153, or by phone at (800) 381-0645.

A written summary of your rights under the Fair Credit Reporting Act (FCRA) as prepared by the Federal Trade Commission is available upon request. You also have the right to review the information obtained from previous employers, to correct errors in that information and rebut perceived incorrect information. Such requests must be made in writing prior to accepting employment with the Company.

TO BE READ AND SIGNED BY APPLICANT
I give the motor carrier and its agents or representatives the right to investigate all references and to secure additional information about my employment background. I hereby release from all liability for damages the motor carrier and its agents or representatives for seeking such information and all other persons, corporations or organizations for furnishing such information.

I authorize you to make such investigations and inquiries of my personal, employment, financial, or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.) I hereby release employers, schools, health care providers and other such persons from all liability in responding to inquiries and releasing information in connection with my application.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the Company.

I understand that information I provide regarding current and/or previous employers may be used, and those employer(s) will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23(d) and (e). I understand that I have the right to:

  • Review Information provided by previous employers;
  • Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to the prospective employer; and
  • Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information.
I agree to furnish such additional information and complete such examinations as may be required to complete my employment files.
It is agreed and understood that this application for qualification in no way obligates the motor carrier to employ me.
It is agreed and understood that if qualified to operate motor carrier equipment, I may be on a probationary period, during which I may be disqualified without recourse.

Applicant's Electronic Signature: 



 I UNDERSTAND CHECKING THIS BOX THIS CERTIFIES THAT THIS APPLICATION WAS COMPLETED BY ME, AND THAT ALL ENTRIES ON IT AND INFORMATION IN IT ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE.

Home |  Types of Equipment |  Image Gallery |  Online Application |  Contact Us